Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker | SW127377 | PA |
NPI | 1003138645 |
---|---|
Provider Name | Theresa Diane Edwards |
First Address | Braddock, PA 15104-1463 |
Second Address | Braddock, PA 15104-1463 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/02/2010 |
Last Update Date | 13/09/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1024653590003 | (05) | PA |